Failure to Maintain Advance Directive Documentation
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that an advance directive or a Physician Orders for Life-Sustaining Treatment (POLST) form was completed and available in the clinical record for one of two sampled residents. Review of the resident's clinical record showed no completed POLST form, despite the resident's admission to the facility. During an interview and concurrent record review, the DON confirmed the absence of the POLST form in the resident's records and suggested it may have been misplaced. Facility policy requires that information about whether a resident has executed an advance directive be displayed prominently in the medical record, and that a copy of the POLST form be retained in the patient's medical record.